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FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -` Permit No ...10 --------- <br /> (Complete in Triplicate) <br /> ----------------------------------------------- <br /> ------ - Date Issued_/",�A-7-.� <br /> _---.--__----_-__- <br /> -------------_- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION `- ---------- ------- ------------------------------CENSUS TRACT.----------- ----- --------- <br /> ------------ <br /> -------- f <br /> �,` '4.. `._---- _- - ' _Phone -3 ---------- <br /> Ia i <br /> Owner's Name------------ -- -- �7 <br /> Address---- ------------- -: (S/ �`"��-------------------- City <br /> ,a Zi'P <br /> Contractor's Name----------�---- ----- -- --- -=-- --- <br /> -- ------- ---------------L-icense #��-.3�3_------Phone- /4O- <br /> � ------ <br /> Installation will serve: ,Residence Apartment,House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------------ -------------------------- ----- <br /> Number of living units:--- ------------N tuber of bedrooms--?.----Garbage Grinder.-----------Lot Size-------fes" .- - ................................... 4 <br /> Water Supply: Public System and name.---- -----------°-------------------------------------------------- ------------ -----------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑` Adobe [ Fill Material--.---------If yes, type-------------------------------- <br /> 4 <br /> {Plot plan, showing size of lot, location of system in relation to wells;buildings, etc: must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> .(-- e <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth.-------------------------- <br /> Capacity---------- ----------Type--:--------------------Material--------------------------No. Compartments - ------------------------------- <br /> Distance <br /> --------=-------------------- <br /> Distance to nearest: Well.. _ - ..�_. Foundation -------------------------Prop. Line--------------------------- <br /> LEACHING LINE [ ] No. of Lines-----'------------------------Length ofv.ecil&line-----------------------------.Total Length---------------------------------------- <br /> 'D' Box------- ----Type Filter Material----------------------------- Filter Material---------------------------------------------------------------- <br /> Distance <br /> -----:------------------------------------ <br /> Distance to nearest: Well----------------------------Found-6tion----_nN_. --------------Property,,Line-------- ----------------.-------- <br /> SEEPAGE PIT [ ] Depth--- -----------Diameter.---_.____---------Number- -_-- Rock Filled Yes El No E] <br /> WaterTable Depth--------------------------------------------=-------------Rock Size.----------------- ----- ----------------------- <br /> Distance to nearest: Well---------------------------------------- Foundation.------------------------ Prop. Line -------------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------_...---.------------- Date----------------------------------------------] <br /> Septic Tank (Specify Requirements) r ------- - ----- ------------ <br /> ,Q <br /> Disposal Field (Specify Requirements)------------ u -------------------------------------------- <br /> . x (�_ - n ------------ <br /> r_ i ,.-Z . _--"� . --------------------------------- ---------------- <br /> ----------------------------------------- ------------------------------------------------------------ _------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations-of-the-San-Joaquin-Local-Health District..Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed------- ------------- ------- -- --------- --- ------------------------- ---Owner 4W <br /> ----------------Title-------` i------- ------------------- ------------------- -- <br /> By------- '----- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY' <br /> `'`' ` DATE.------- `-0 n_-s--------- <br /> APPLICATION ACCEPTED BY- <br /> - <br /> ------------ --------------------------------------------------------DATE <br /> DIVISION OF LAND NUMBER-- <br /> ADDITIONALCOMMENTS--------- ------- -- ------------------- ---------------I---------------------- ----------- <br /> ------------------------------- <br /> --- -------------------------------------------------------------------- ------ ----------------------------------------------------------------------------- <br /> -------------------------------------------------------------- <br /> Final Inspection by:-. _ Date--/_J. d <br /> --------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21h77 REV. 7/76 3M <br /> �y <br />